Medihelp excludes the following from benefits, except in the case of statutory Prescribed Minimum Benefits (PMB):
Exercixe, guidance and rehabilitation programmes.
Treatment of impotence.
Treatment of occupational diseases.
Services rendered by social workers.
Completion of medical and other questionnaires not requested by Medihelp.
Costs of evidence in a lawsuit.
Costs of visits at home and home programmes.
Costs exceeding the scheme tariff for a service or the maximum benefit limit to which a member is entitled, subject to Annexure 2 of the Rules.
Food substitutes, food supplements and patent food, including baby food.
Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics).
Slimming remedies, provided that benefits shall be considered if motivation by a medical specialist as life-essential to be used for a limited period, and if approved beforehand by the Principle Officer.
All patent substances, suntan lotions, anabolic steroids, contact lens solutions
Substances not registered by the South African Medicines Control Council, except in the case of medicine items approved by Medihelp in the following instances:
medicine items with patient-specific exemptions in terms of section 21 of the Medicines and Related Substances Control Act, 1965 (Act No 101 of 1965) as amended;
homeopathic and naturopathic medicine items that have valid NAPPI codes as well as compounded non-proprietary medicine items dispensed by a homeopath/naturopath; and
where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
When only accommodation and/or general care services are rendered.
The cost of transport with an ambulance/emergency vehicle –
from a hospital/other institution to a residence;
in the event of self-inflicted injury, unless it is a Prescribed Minimum Benefit;
in the event of a visit to friends/family; and
to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does not pertain to admission in a hospital.
The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells, for future use thereof to treat a medical condition which has not yet been diagnosed in a beneficiary.
Breast augmentation (applicable to the Dimension Prime range).
Breast reduction (applicable to the Dimension Prime range).
Gastroplastry (applicable to the Dimension Prime range).
Gender reversal operations (applicable to the Dimension Prime range).
Lipectomy (applicable to the Dimension Prime range).
Epilation (applicable to the Dimension Prime range).
Otoplasty/reconstruction of the ear (applicable to the Dimension Prime range).
Refractive procedures (applicable to the Dimension Prime range).
Obesity (applicable to the Dimension Prime range).
All biological and other medicine items as per Medihelp's medicine exclusion list (applicable to the Dimension Prime range).
Hip, knee and shoulder replacements (applicable to the Dimension Prime 1, Dimension Prime 2 and Dimension Prime 3).
Sclerotherapy (applicable to the Dimension Prime range).
Appliances such as blood pressure apparatus, mattresses and magnifying readers.
Hymenectomy and circumcision (applicable to Dimension Prime 1).
Removal of impacted wisdom teeth during hospitalisation (applicable to Dimension Prime 1 and Dimension Prime 2).
Insulin pumps and related consumables (applicable to the Dimension Prime 1, Dimension Prime 2 and Dimension Prime 3).
Pathology services requested by naturopaths, herbalists and homeopaths.
High technology treatment modalities, surgical appliances and medicine (applicable to the Dimension Prime range).
Nutritional and tobacco counselling.
Caries susceptibility and microbiological tests.
Electrognathographic recordings and other such electronic analyses.
Fissure sealants on patients older than 16 years.
Replacement of amalgam (silver) fillings with composite (white) fillings.
Gold foil restorations.
Pulp capping (direct and indirect).
Polishing of restorations.
Ozone therapy.
Metal base to full dentures, including the laboratory cost.
Crown and bridge procedures for cosmetic reasons and the associated laboratory costs.
Diagnostic dentures and the associated laboratory costs.
Provisional crowns and the associated laboratory costs.
Emergency crowns that are not placed for the immediate protection in tooth injury, and the associated laboratory costs.
Resin bonding for restorations charged as a separate procedure.
Dental bleaching.
Porcelain veneers and inlays and the associated laboratory costs.
Orthodontic treatment for cosmetic reasons.
The auto-transplantation of teeth.
The closure of an oral-antral opening when claimed during the same visit with impacted teeth.
Where the reason for admission to hospital is dental fear or anxiety.
Where the only reason for admission to hospital is to acquire a sterile facility.
Perio chip.
The hospital and anaesthetic claims for the following procedures will not be covered when performed under general anaesthesia:
Apisectomies.
Dentectomies.
Frenectomies.
Soft-tissue impactions.
Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults.
Professional oral hygiene procedures.
Implantology and associated surgical procedures.
Surgical tooth exposure for orthodontic reasons.
Removal of impacted wisdom teeth unless covered by bone.
Orthognathic (jaw correction) surgery and the related hospital cost, and the associated laboratory costs.
Sinus lift.
Bone augmentations.
Bone and other tissue regeneration procedures and the cost of material.
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis.
Surgical periodontics which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a tooth.
Orthodontic re-treatment and the associated laboratory costs.
The cost of dental materials for procedures performed under general anaesthesia.
Dolder bars and associated abutments on implants, including the associated laboratory costs.
The laboratory costs, where the associated dental treatment is not covered.
The laboratory cost associated with mouth guards. The clinical fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
Snoring appliances and the associated laboratory costs.
High-impact acrylic.
Cost of mineral trioxide.
Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.
The cost of gold, precious metal, semi-precious metal and platinum foil.
Cost of invisible retainer material.
Cost of bone regeneration material.
Appointments not kept.
Professionally applied topical fluoride in adults.
Laboratory delivery fees.
Special reports.
Dental testimony.
Enamel microabrasion.
Behaviour management.
Intramuscular and subcutaneous injections.
Procedures that are defined as unlisted procedures.
The clinical fee for the addition of a soft tissue base to new dentures. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
The clinical fee for denture repairs and denture tooth replacements. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
Multiple hospital admissions.
Full mouth rehabilitations and the associated laboratory costs.
Root canal therapy on primary (milk) teeth.
Provisional dentures and associated laboratory costs.
Treatment plan completed (code 8120).